Professional Documents
Culture Documents
2014 Imci Chart Booklet Final-1
2014 Imci Chart Booklet Final-1
YOUNG INFANT
(BIRTH UP TO 2 MONTHS)
IMCI process for all Young Infants.......................2 Assess, Classify and Identify Treatment
Helping Babies Breathe.........................................3 General Danger Signs............................................25
Cough or difficult breathing....................................26
Wheezing...............................................................26
Assess, Classify and Identify Treatment
Possible Bacterial Infection .......4 Diarrhoea................................................................27
Jaundice........4 Fever......................................................................28
Diarrhoea ..................5 Measles..................................................................29
Congenital problems ...... 6 Ear problem............................................................30
Risk Factors..........7 Sore throat..............................................................30
HIV Infection.....8 Malnutrition ............................................................31
Feeding and Growth ...9 Anaemia.................................................................32
Feeding and Growth in non-Breastfed Infants.....10 HIV infection...........................................................33
Immunization Status..... .........................................11 TB...........................................................................34
Other Problems.............................................11 Immunization status...............................................35
Caregivers health......... .........................................11 Other problems.......................................................35
Maternal Danger Signs.........................................11 Caregivers health..................................................35
Routine treatments (Vitamin A and deworming).....35
Treat the Young Infant
Prevent Low Blood Sugar....12
Treat Low Blood Sugar..........12
Give Oxygen...12
Keep the infant or child warm......12
Ceftriaxone...13
Penicillin......13
Cephalexin......13
Nevirapine........13
Treat sticky eyes....13
Diarrhoea....14
Local Infections ......14
Counsel the Caregiver
Advise Caregiver to Give Home Care ....15
When to Return......................................................15
Give Follow-up Care
Local Bacterial Infection.........................................16
Jaundice.................................................................16
Feeding Problems..................................................16
Poor Growth...........................................................16
Thrush....................................................................16
ANTI-RETROVIRAL THERAPY
(ART)
Iron......................................................................42
Ready to Use Therapeutic Food (RUTF).............42
Multivitamins........................................................42
Zinc......................................................................42
SKIN PROBLEMS
ANNEXURES
Developmental screening
Growth monitoring chart for girls
Growth monitoring chart for boys
Recording form for newborn care and young infant
Recording form for child 2 months to 5 years
Breastfeeding Assessment..........................................................................................21
Support mothers to breastfeed successfully...............................................................21
Support on expressing breastmilk and cupfeeding.....................................................22
Counsel the caregivers about giving replacement feeds.............................................23
Counsel the caregiver about giving the correct volume and frequency of feeds.........24
Counsel the caregiver about feeding a child with Severe Acute Malnutrition..............24
South Africa 2014
YES
NO
or ROUTINE VISIT
Ensure that an infant who has come for an INITIAL
IF THE INFANT BEEN BROUGHT TO THE FACILITY BECAUSE S/HE IS SICK (INITIAL VISIT):
URGENTLY ASSESS and CLASSIFY for POSSIBLE
SERIOUS BACTERIAL INFECTION (p. 4)
Then complete the YOUNG INFANT assessment (p. 5 11)
Provide treatment (including pre-referral treatment and referral if required)
Counsel the caregiver on Home Care for the Young Infant
and When to Return (p. 15)
Assess breastfeeding and support the mother to successfully breastfeed the infant (p. 20 - 22)
ASK:
Classify ALL
young infants
YOUNG
INFANT
MUST
BE CALM
POSSIBLE
SERIOUS
BACTERIAL
INFECTION
LOCAL
BACTERIAL
INFECTION
Classify ALL
young
infants
No jaundice
NO
BACTERIAL
INFECTION
SEVERE
JAUNDICE
JAUNDICE
NO
JAUNDICE
for
DEHYDRATION
IF YES, ASK:
SEVERE
DEHYDRATION
SOME
DEHYDRATION
Classify
DIARRHOEA
AND diarrhoea 14
days or more
NO VISIBLE
DEHYDRATION
SEVERE
PERSISTENT
DIARRHOEA
AND if blood in
stool
SERIOUS
ABDOMINAL
PROBLEM
Refer URGENTLY.
Keep the infant warm on the way to
hospital (p. 12)
THEN ASK: WAS THE YOUNG INFANT EXAMINED BY A HEALTH WORKERS AFTER BIRTH?
IF NO, ASSESS FOR CONGENITAL PROBLEMS
ASK:
Classify
Young
Infant
MAJOR
ABNORMALITY
OR SERIOUS
ILLNESS
POSSIBLE
CONGENITAL
SYPHILIS
NO BIRTH
ABNORMALITIES
Mother is on TB treatment
TB EXPOSED
AT RISK
INFANT
POSSIBLE
SOCIAL
PROBLEM
Classify ALL
young infants
No risk factors
Counsel the caregiver on home care for the young infant (p. 15)
NO RISK
FACTORS
ONGOING HIV
EXPOSURE
NOTE:
All HIV-exposed children should have an HIV antibody test done at 18
months of age, EXCEPT those already confirmed to be PCR positive and
on ART (as this may give a false negative result).
Was the mother tested for HIV during pregnancy or since the child
was born?
If YES, was the test negative or positive?
HIV EXPOSED
HIV UNKNOWN
HIV UNLIKELY
Classify child
according to
Mothers HIV
status
Classify
FEEDING in all
young infants
suckling well
FEEDING
PROBLEM
POOR
GROWTH
Thereafter minimum weight gain should be: Preterm: 10g/kg/day or Term: 20g/kg/day
THEN CHECK FOR FEEDING AND GROWTH (Alternative chart for non-Breastfed infants)
ASK:
How is feeding going?
Plot the weight on the RTHB to determine the weight for age.
Classify
FEEDING and
GROWTH in all
young infants
NOT ABLE
TO FEED
Milk incorrectly or
unhygienically prepared.
or
Giving inappropriate replacement milk or other foods/
fluids.
or
Giving insufficient replacement feeds.
or
Using a feeding bottle.
or
Thrush
NOTE:
Young infants may lose up to 10% of their birth weight in the first few days after
birth, but should regain their birthweight by ten days of age
Thereafter minimum weight gain should be:
Preterm: 10g/kg/day OR Term: 20g/kg/day
10
FEEDING
PROBLEM
POOR
GROWTH
FEEDING
AND
GROWING
WELL
THEN CHECK THE YOUNG INFANTS IMMUNISATION STATUS AND IMMUNISE IF NEEDED
IMMUNISATION
SCHEDULE:
Birth
BCG
OPV0
6 weeks
DaPT-Hib-IPV1
OPV1
10 weeks
DaPT-Hib-IPV2
HepB1
PCV1
RV1
HepB2
11
Give Oxygen
Low blood sugar 1.4 to less than < 2.5 mmol/L in a young infant
Breastfeed or feed expressed breastmilk.
If breastfeeding is not possible give 10mg/kg of replacement milk feed
Repeat the blood glucose in 15 minutes while awaiting transport to hospital
If the blood sugar remains low, treat for severe hypoglycaemia (see below)
If the blood glucose is normal, give milk feeds and check the blood glucose 2-3 hourly
Low blood sugar < 1.4 mmol/L in a young infant
grunting
Use nasal prongs or a nasal cannula.
Nasal prongs
Place the prongs just below the babys nostrils. Use 1mm prongs for small babies and 2mm
prongs for term babies
Secure the prongs with tape
Oxygen should flow at one litre per minute
Nasal cannula
12
Give Nevirapine
Give once daily
CEFTRIAXONE
250 mg in 1 ml
2 - < 3 kg
0.5 ml
3 - 6 kg
1 ml
All HIV-exposed infants should be given daily Nevirapine for six weeks.
The first dose should be given as soon after birth as possible, and must be given within 72 hours (3 days).
Remember to do an HIV PCR test on the infant when the infant is six weeks old, and six weeks after the
child has stopped breastfeeding. If the child tests positive for HIV infection, stop Nevirapine and initiate
ART (p. 53)
Nevirapine should be continued after six weeks of age in the following cases:
- If the mother started ART less than four weeks before delivery, at delivery or post-delivery, the infant
should receive nevirapine up to 12 weeks of age.
- If the mother is not on ART, the infant should receive nevirapine until one week after cessation of all
breastfeeding.
- If the mothers viral load is > 1000mL despite ART, seek expert advice for the treatment of both
mother and child
If the child is underweight for age (WA z-score< -3) give according to weight i.e. 4mg/kg/dose daily
AGE
BIRTH WEIGHT
1 ml
2.5 kg or more
1.5 ml
Birth to 6 weeks
6 weeks up to 6 months
2 ml
6 months up to 9 months
3 ml
4 ml
Cephalexin syrup
125 mg in 5 ml
Flucloxacillin syrup
125 mg in 5 ml
Up to 5 kg
2.5 ml
2.5 ml
5kg
5 ml
5 ml
13
WEIGHT
BENZATHINE BENZYLPENICILLIN
300 000 units in 1 ml
0.5 ml
3.5 - < 5 kg
0.75ml
> 5 kg
1 ml
If there is DIARRHOEA WITH SEVERE DEHYDRATION or DIARRHOEA WITH SOME DEHYDRATION (p.43 44)
Explain how the treatment is given
If there is SEVERE DEHYDRATION commence intravenous rehydration, give the first dose of ceftriaxone IM (p. 13) and REFER URGENTLY.
clean utensils used to prepare and administer the milk (p. 22 - 24).
14
COUNSEL THE MOTHER OR CAREGIVER ON HOME CARE FOR THE YOUNG INFANT
1. FLUIDS AND FEEDING
Ensure good communication with the mother to promote early and exclusive breastfeeding (p. 17 - 21)
Counsel the mother to breastfeed frequently, as often and for as long as the infant wants, day or night, during sickness and health (p. 17 - 21)
2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES
Encourage mother to keep infant warm using skin-top-skin contact (p. 12)
In cool weather, cover the infants head and feet and dress the infant with extra clothing.
3. MAINTAIN A HYGIENIC ENVIRONMENT
Advise the caregiver to wash her hands with soap and water after going to the toilet, changing the infants nappy and before each feed.
4. SUPPORT THE FAMILY TO CARE FOR THE INFANT
Help the mother, family and caregiver to ensure the young infants needs are met.
Assess any needs of the family and provide or refer for management.
4. WHEN TO RETURN
Follow-up Visits
2 days
7 days
AT RISK INFANT
POSSIBLE SOCIAL PROBLEM
1 day
HIV INFECTION
ONGOING HIV EXPOSURE
HIV EXPOSED
TB EXPOSED
Follow-up in:
As needed
15
FEEDING PROBLEM
After 2 days:
After 1 or 2 days:
Discharge of eyes: has the discharge improved? Are the lids swollen?
Red umbilicus: Is it red or draining pus? Does redness extend to the skin?
Skin pustules: Are there many or severe pustules?
Treatment:
Ask about any feeding problems found on the initial visit and reassess feeding (p. 9 or 10).
Counsel the caregiver about any new or continuing feeding problems. If you counsel the
caregiver to make significant changes in feeding, ask her to bring the young infant back
again after 5 days.
If the young infant has POOR GROWTH (low weight for age or has poor weight gain), ask
the caregiver to return again after 5 days to measure the young infants weight gain.
Continue follow-up until the weight gain is satisfactory.
If the young infant has lost weight, refer.
EXCEPTION: If the young infant has lost weight or you do not think that feeding will improve, refer
POOR GROWTH
JAUNDICE
After 2 days in infant less than 2 weeks or 7 days in infant more than 2 weeks:
After 1 day:
EXCEPTION: If you do not think that feeding will improve, or if the young infant has lost weight,
refer.
THRUSH
After 2 days:
Look for thrush in the mouth.
Reassess feeding. (p. 9 or 10).
Treatment:
If thrush is worse check that treatment is being given correctly, and that the mother has been treated for
16
17
FEEDING RECOMMENDATIONS
Up to six months
6 months up to 12 months
Continue to breastfeed as
examples below).
Immediately after birth, put your
in 24 hours.
Do not give other foods or fluids, not
even water.
Above 2 years
Meat (especially kidney, spleen, chicken livers), dark green leafy vegetables, legumes (dried beans, peas and lentils).
Iron is absorbed best in the presence of vitamin C.
Tea, coffee and whole grain cereal interfere with iron absorption.
COWS MILK
Cows or other animal milks are not suitable for infants below 6 months of age
(even modified).
For a child between 6 and 12 month of age: boil the milk and let it cool (even if pasteurized).
Feed the baby using a cup (p. 22).
Vegetable oil, liver, mango, pawpaw, yellow sweet potato, Full Cream Milk, dark
green leafy vegetables e.g. spinach / imfino / morogo.
Recommend that the child be given an extra meal a day for a week once better.
18
FEEDING ASSESSMENT
Assess the Childs Feeding if the child is:
classified as having:
ACUTE SEVERE MALNUTRITION WITHOUT MEDICAL COMPLICATIONS
MODERATE SEVERE MALNUTRITION
NOT GROWING WELL
ANAEMIA
under 2 years of age
Ask questions about the childs usual feeding and feeding during this illness.
Compare the mother/caregivers answers to the Feeding Recommendations for
the childs age (p. 18).
ASK:
How are you feeding your child?
Are you breastfeeding?
How many times during the day?
Do you also breastfeed at night?
Are you giving any other milk?
What type of milk is it?
What do you use to give the milk?
How many times in 24 hours?
How much milk each time?
How is the milk prepared?
How are you cleaning the utensils?
What other food or fluids are you giving the child?
How often do you feed him/her?
What do you use to give other fluids?
How has the feeding changed during this illness?
If the child is not growing well, ASK:
How large are the servings?
Does the child receive his/her own serving?
Who feeds the child and how?
19
WEIGHT
SACHETS
(APPROX 90G)
4 - < 7 kg
to
7 - < 10 kg
to
10 - < 15 kg
to
15 - < 30 kg
to 1
>30kg
>1
Identify the reason for the mothers concern and manage any breast condition.
If needed, show recommended positioning and attachment (p. 21).
Build the mothers confidence.
Advise her that frequent feeds improve lactation.
If the child has a poor appetite, or is not feeding well during this illness,
counsel the caregiver to:
Breastfeed more frequently and for longer if possible.
Use soft, varied, favourite foods to encourage the child to eat as much as
possible.
Give foods of a suitable consistency, not too thick or dry.
Avoid buying sweets, chips and other snacks that replace healthy food.
Offer small, frequent feeds. Try when the child is alert and happy, and give
more food if he/she shows interest.
Clear a blocked nose if it interferes with feeding.
Offer soft foods that dont burn the mouth, if the child has mouth ulcers /
sores e.g. eggs, mashed potatoes, sweet potatoes, pumpkin or avocado.
Ensure that the spoon is the right size, food is within reach, child is actively
fed, e.g. sits on caregivers lap while eating.
Expect the appetite to improve as the child gets better.
If there is no food available in the house:
Help caregiver to get a Child Support Grant for any of her children who are
eligible.
Put her in touch with a Social Worker and local organisations that may assist.
Encourage the caregiver to have or participate in a vegetable garden.
Supply milk and enriched (energy dense) porridge from the Food Supplementation programme.
Give caregiver appropriate local recipes for enriched (energy dense) porridge.
If the child is not being fed actively, counsel the caregiver to:
Sit with the child and encourage eating.
Give the child an adequate serving in a separate plate or bowl.
20
If baby has not fed in the last hour, ask mother to put baby to the breast.
Observe the breastfeed for 4 minutes. (If baby was fed during the last hour,
ask mother if she can wait and tell you when the infant is willing to feed
again).
Is baby able to attach?
not at all
poor attachment
good attachment
Is the baby suckling well (that is, slow deep sucks, sometimes pausing)?
not at all
suckling well
21
22
Replacement feeds
Breastfeeding is the perfect food for the baby. It contains many antibodies and
substances that fight infection, mature the gut and body, and promote optimal
growth, development and health for the baby
The risk of not breastfeeding is a much higher chance of the baby becoming ill
with, or even dying from, diarrhoea, pneumonia or malnutrition.
If the mother is HIV positive, with ART prophylaxis the risk of HIV transmission is
much less than in the past.
Ensure that the mother understands the benefits of breastfeeding and risks of not breastfeeding
Prepare correct strength and amount of replacement feeds before use. (p. 24).
The mother or caregiver must purchase all the formula herself, and be prepared
to do this for 12 months.
Disclosure of her HIV status to relevant family will make it easier as she must
give formula only and no breast milk
She must safely prepare milk before EACH of 6 8 feeds a day
Running water in the house and electricity and a kettle are advisable for safe
preparation of 6 8 feeds a day.
She must be able to clean and sterilise the equipment after each feed
She should use a cup to feed the baby as it is safer than a bottle (p. 22)
If the mother (or caregiver) nevertheless chooses to breastfeed, ensure that she understands the
requirements for safe replacement feeding and knows how to prepare replacements feeds safely.
Infants who are on replacement feeds should receive no other foods or drinks until six months of age
Young infants require to be fed at least 8 times in 24 hours.
Cup feeding is safer than bottle feeding. Use a cup which can be kept clean i.e. not one with a spout
(p. 22)
Pasteurised full cream milk may be introduced to the non-breastfed infants diet from 12 months of
age.
Where infant formula is not available, children over six months may temporarily receive undiluted
pasteurised full cream milk (boiled), provided that iron supplements or iron-fortified foods are consumed and the amount of fluid in the overall diet is adequate.
Boil the water. If you are boiling the water in a pot, it must boil for three minutes. Put the If the infant is being cupfed:
pots lid on while the water cools down. If using an automatic kettle, lift the lid of the
Wash all containers and utensils used for feeding and preparation thoroughly in hot soapy
kettle and let it boil for three minutes.
water. Make sure that all remaining feed is removed. Rinse with clean water, allow to dry
The water must still be hot when you mix the feed to kill germs that might be in the powor dry with a clean cloth and store in a clean place.
der.
If possible, all containers and utensils should be sterilized once a day as described below.
Carefully pour the amount of water that will be needed in the marked cup. Check if the
water level is correct before adding the powder. Measure the powder according to the
instructions on the tin using the scoop provided. Only use the scoop that was supplied
with the formula.
water. Make sure that all remaining feed is removed using a bottle brush. Rinse with
clean water.
The bottles and other equipment must be sterilised after each use as described below.
Cool the feed to body temperature under a running tap or in a container with cold water. Sterilization should be done as follows:
Pour the mixed formula into a cup to feed the baby.
fill a large pot with water and completely submerge all washed feeding and preparation
equipment, ensuring there are no trapped air bubbles
Only make enough formula for one feed at a time.
cover the pot with a lid and bring to a rolling boil, making sure the pot does not boil dry
Feed the baby using a cup (p. 22) and discard any leftover milk within two hours.
keep the pot covered until the feeding and preparation equipment is needed.
Cleaning of equipment used for preparation and giving of feeds.
23
Age
Weight
Approximate
amount of
Feed needed in
24 hours
Approximate
no. of feeds
per day.
Birth
3 kg
400ml
8 X 50ml
2 weeks
3 kg
400ml
8 X 50ml
6 weeks
4 kg
600ml
7 X 75ml
10 weeks
5 kg
750ml
6 X 125ml
14 weeks
6.5 kg
900ml
6 X 150ml
4 months
7 kg
1050ml
6 X 175 ml
5 months
7 kg
1050ml
6 X 175 ml
6 months
8 kg
1200ml
6 X 200ml
7 to 12 months
8 - 9 kg
1000ml
4 x 250 ml
NOTE: For formula feeding preparations, advise the caregiver to always use the correct amount of water and formula
according to the product instructions
24
ASSESS
CLASSIFY AS:
LOOK:
Is the child lethargic or
unconscious?
Is the child convulsing
now?
Classify
ALL
CHILDREN
Any general
danger sign
VERY
SEVERE DISEASE
A CHILD WITH ANY GENERAL DANGER SIGN NEEDS URGENT ATTENTION AND REFERRAL:
QUICKLY COMPLETE THE ASSESSMENT, GIVE PRE-REFERRAL TREATMENT IMMEDIATELY AND REFER AS SOON AS POSSIBLE
25
IF YES, ASK:
Classify
COUGH or
DIFFICULT
BREATHING
CHILD
MUST BE
CALM
PNEUMONIA
Fast breathing
If the pulse
oximeter is
available then determine
oxygen saturation
No signs of
pneumonia or very
severe disease
COUGH OR COLD
SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE
AND if
WHEEZE
Classify
RECURRENT WHEEZE
All other children with
wheeze
WHEEZE
(FIRST EPISODE)
FAST BREATHING
If the child is:
2 months up to 12 months
12 months up to 5 years
26
LOOK OR FEEL:
Classify
Dehydration present
OR
Losing weight
and if diarrhoea
14 days or
more
and if blood in
stool
SEVERE
DEHYDRATION
SOME
DEHYDRATION
NO VISIBLE
DEHYDRATION
SEVERE
PERSISTENT
DIARRHOEA
PERSISTENT
DIARRHOEA
No visible dehydration.
Dehydration present
OR
Age less than 12 months
27
SEVERE
DYSENTERY
DYSENTERY
Refer URGENTLY
Keep child warm (p. 12)
Test for low blood sugar, then treat or prevent
(p. 36)
ASK
For suspected
meningitis
SUSPECTED
MENINGITIS
Classify
FEVER
AND if Malaria
Risk
SUSPECTED
SEVERE
MALARIA
MALARIA
28
SUSPECTED
MALARIA
FEVER
OTHER CAUSE
MEASLES: Use this chart if the child has Fever and Generalised rash WITH Runny nose or Cough or Red eyes
ASK:
LOOK:
Classify for
MEASLES
SUSPECTED
COMPLICATED
MEASLES
MEASLES
SUSPECTED
MEASLES
NOTE:
29
Classify
EAR PROBLEM
ACUTE EAR
INFECTION
CHRONIC EAR
INFECTION
NO EAR
INFECTION
If the child is three years old or older, ASK: Does the child have a sore throat?
IF YES, ASK:
Does the child have a
runny nose?
Does the child have a
FEVER?
Does the child have a
cough?
Classify
SORE THROAT
30
POSSIBLE
STREPTOCOCCAL
INFECTION
SORE THROAT
AND
One or more of the following:
Any danger sign
Any RED or YELLOW classification
Weighs 4 kg or less
Is less than six months of age
Is not able to finish RUTF
(fails the Apetite Test (p.19))
WFL/H Z-score < - 3
or
MUAC < 11.5 cm.
AND
Able to finish RUTF
No oedema of both feet
Six months or older
Weighs 4 kg or more
No other RED or YELLOW
classification
Losing weight
OR
Weight gain unsatisfactory
31
SEVERE ACUTE
MALNUTRITION
WITH MEDICAL
COMPLICATION
ACUTE
MALNUTRITION
WITHOUT
MEDICAL
COMPLICATION
MODERATE
ACUTE
MALNUTRITION
NOT GROWING
WELL
GROWING WELL
LOOK:
Look for palmar pallor. Is there:
Severe palmar pallor?
Some palmar pallor?
If any pallor, check haemoglobin (Hb) level.
Classify all
children
for ANAEMIA
No pallor.
Refer URGENTLY
SEVERE
ANAEMIA
ANAEMIA
NO ANAEMIA
Give iron (p. 42) and counsel on iron-rich foods (p. 18)
Assess feeding and counsel regarding any feeding problems
(p. 18 - 24)
Treat for worms if due (p. 35)
Advise caregiver when to return immediately (p. 46)
Follow-up in 14 days (p. 49)
If child is less than 2 years, assess feeding and counsel (p.
18 - 20)
NOTE:
DO NOT give Iron if the child is receiving RUTF. Small amounts are available in RUTF.
Iron is extremely toxic in overdose, particularly in children All medication should be stored out of reach of children.
32
HIV
INFECTION
ONGOING HIV
EXPOSURE
OR
Classify
for HIV infection
in the child
HIV NEGATIVE
3 or more features of
HIV infection.
SUSPECTED
SYMPTOMATIC
HIV INFECTION
HIV EXPOSED
POSSIBLE HIV
INFECTION
HIV INFECTION
UNLIKELY
ASK:
Has the mother had an HIV test? If YES, was it negative or positive?
Classify for
HIV infection
Note:
If clinical findings suggest HIV infection but the rapid test is negative, send a further
specimen of blood to the laboratory for formal ELISA testing. If unsure discuss with
an expert or refer the child.
No features of HIV
infection
33
Stop cotrimoxazole
Consider other causes if child has features of HIV
infection (repeat HIV test if indicated).
Classify
for
TB RISK
FULL TB ASSESSMENT
STEP 1: ASK ABOUT FEATURES OF TB:
Persistent, non-remitting cough or wheeze for more than 2 weeks.
Documented loss of weight or unsatisfactory weight gain during the past 3
months (especially if not responding to deworming together with food and/or
micronutrient supplementation).
Fatigue/reduced playfulness.
Fever every day for 14 days or more.
STEP 2: SEND SPUTUM OR GASTRIC ASPIRATE FOR EXPERT AND CULTURE
STEP 3: DO A TST
No close TB contact
AND
No features of TB
A close TB contact
AND
No features of TB
A close TB contact.
AND
Answers YES to any of
screening questions
Classify
For
TB
NOTE:
* A close TB contact is an adult who has had pulmonary TB in the last 12 months,
who lives in the same household as the child, or some-one with whom the child is
in close contact or in contact for extended periods. If in doubt, discuss the case
with an expert or refer the child.
No features of TB present
AND
Close TB contact or TST positive
No close TB contact
AND
No features of TB present
Do Full TB assessment
Follow-up after 48 to 72 hours to read TST
HIGH RISK OF TB Follow-up after one week and classify childs TB status on the next
chart.
RISK OF TB
TB EXPOSED
Do Full TB assessment
Follow-up after 48 to 72 hours to read TST
Follow-up after one week and classify childs TB status on the next
chart
Treat with INH for 6 months (p. 39)
If CXR available send for CXR. If CXR abnormal, refer for assessment
Trace other contacts
Follow-up monthly (p. 52)
Routine care
LOW RISK OF TB
CONFIRMED TB
PROBABLE TB
POSSIBLE TB
TB EXPOSED
TB UNLIKELY
If you are unsure about the diagnosis of TB, refer the child for assessment and
investigation.
34
THEN CHECK THE CHILDS IMMUNIZATION STATUS AND GIVE ROUTINE TREATMENTS
IMMUNIZATION
SCHEDULE:
Birth
6 weeks
10 weeks
14 weeks
BCG
DaPT-Hib-IPV1
DaPT-Hib-IPV2
DaPT-Hib-IPV3
OPV0
OPV1
9 months
18 months
DaPT-Hib-IPV4
6 years
Td
12 years
Td
HepB1
HepB2
HepB3
PCV1
RV1
PCV2
RV2
Measles1
PCV3
Measles2
ASSESS ANY OTHER PROBLEM e.g. Skin rash or infection, eye infection
CHECK THE CAREGIVERS HEALTH
Give Vitamin A
Give Mebendazole
Give Vitamin A routinely to all children from the age of 6 months to prevent severe illness (prophylaxis).
If the child has had a dose of Vitamin A in the past 30 days, defer Vitamin A until 30 days has elapsed.
Vitamin A is not contraindicated if the child is on multivitamin treatment.
Vitamin A capsules come in 100 000 IU and 200 000 IU.
Record the date Vitamin A given on the RTHB.
Children older than one year of age should receive routine deworming treatment every six
months. Mebendazole is the only medicine recommended by the EDL for deworming.
Give single dose or first dose of Mebendazole in the clinic.
If you are using Albendazole, make sure that you give the correct dose.
Record the dose on the RTHB
ROUTINE VITAMIN A*
MEBENDAZOLE
Age
6 up to 12 months
Vitamin A dose
AGE
Suspension
(100 mg per 5 ml)
Tablet
(100 mg)
12 up to 24 months
2 up to 5 years
25 ml as single
dose
Age
dose
A single dose Additional
of 100 000 IU
at age 6 months or up to 12 months
< 6 months
50 000IU
A single dose of 200 000 IU at 12 months, then a dose of 200 000 IU
1 up to 5 years
every
6 months
up to 5 years
6 up to 12 months
100
000
IU
ADDITIONAL DOSE
SEVERE MALNUTRITION,
PERSISTENT DIARRHOEA,
1 up toFOR
5 years
200 000 IU
MEASLES OR XEROPHTHALMIA*
Give therapeutic (non-routine) dose of Vitamin A if the
child has SEVERE MALNUTRITION, PERSISTENT
DIARRHOEA, measles or xerophthalmia.
If the child has measles or xerophthalmia, give
caregiver a second dose to take the next day.
*Xerophthalmia means that the eye has a dry
appearance
Age
Vitamin A
Additional dose
< 6 months
50 000IU
6 up to 12 months
100 000 IU
1 up to 5 years
200 000 IU
35
Tablet
(500 mg)
One tablet as
single dose
Determine the dose appropriate for the childs weight (or age).
Turn the child to the side and clear the airway. Avoid putting things in the mouth.
Give 0.5 mg per kg diazepam injection solution per rectum. Use a small syringe without a
needle or a catheter.
Test for low blood sugar, then treat or prevent.
Give oxygen (p. 37).
REFER URGENTLY.
If convulsions have not stopped after 10 minutes, repeat the dose once while waiting for
transport.
WEIGHT
AGE
DIAZEPAM
10 mg in 2 ml
3 - < 4 kg
0 up to 2 months
2 mg (0.4 ml)
4 - < 5 kg
2 up to 3 months
5 - < 15 kg
3 up to 24 months
5 mg (1 ml)
15 - 25 kg
2 up to 5 years
Give Ceftriaxone IM
per ml).
Confirm low blood sugar using blood glucose testing strips.
Treat with:
- 10% Glucose - 5 ml for every kg body weight - by nasogastric tube OR intravenous
-
every 24 hours.
line.
Keep warm.
WEIGHT
< 3 kg
WEIGHT
F - 75
3.0 - < 5 kg
60 ml
5 - < 8 kg
90 ml
8 kg
120 ml
AGE
CEFTRIAXONE DOSE IN
MG
CEFTRIAXONE DOSE IN ML
125 mg
ml
250 mg
1.0 ml
0 up to 3 months
3 - < 6 kg
36
6 - < 10 kg
3 up to 12 months
500 mg
2.0 ml
10 - < 15 kg
12 up to 24 months
750 mg
3.0 ml
15 kg
2 up to 5 years
1g
Give Oxygen
Add 1 ml of 1:1000 adrenaline (one vial) to 1 ml of saline and administer using a nebulizer.
Always use oxygen at flow-rate of 6 - 8 litres.
Repeat every 15 minutes, until the child is transferred (or the stridor disappears)
Give one dose of prednisone as part of pre-referral treatment for stridor
WEIGHT
Nasal cannula
Up to 30 kg
3 up to 5 years
1.6 ml
1.5ml
SALBUTAMOL
Nebulised salbutamol
(2.5 ml nebule)
Give one dose of prednisone as part of pre-referral treatment for STRIDOR or for RECURRENT WHEEZE with severe classification.
WEIGHT
AGE
PREDNISONE 5 mg
Up to 8 kg
2 tabs
Up to 2 years
4 tabs
2 - 5 years
6 tabs
OR
MDI - 100 ug per puff
> 8 kg
37
OR
Dilute 1ml in 3 ml saline.
Nebulise in the clinic.
Always use oxygen at flow rate of 6-8 litres.
If still wheezing repeat every 15 minutes in first hour and 2 - 4 hourly
thereafter.
Add Ipratropium bromide 0.5 ml if available
4 - 8 puffs using a spacer.
Allow 4 breaths per puff.
If still wheezing repeat every 15 minutes in first hour and 2 - 4 hourly
thereafter.
TEACH THE CAREGIVER TO GIVE ORAL Give Erythromycin or Azithromycin if allergic to Penicillin
Give erythromycin or azithromycin depending on the childs weight
MEDICINES AT HOME
Give erythromycin for three days for ACUTE EAR INFECTION or for 10 days for POSSIBLE STREPTOFollow the general instructions below for every oral medicines to be
given at home
Also follow the instructions listed with the dosage table for each
medicine
COCCAL INFECTION.
Give azithromycin once daily for three days only.
WEIGHT
AGE
ERYTHROMYCIN
SYRUP
(125 mg per 5 ml)
5 - < 7 kg
3 up to 6 months
3 ml
7 - < 9 kg
6 up to 12 months
4 ml
9 - < 11 kg
12 up to 18 months
5 ml
11 - < 14 kg
18 months up to 3 years
6 ml
14 - < 18 kg
AZITHROMYCIN
TABLET
(250 mg)
8 ml
3 up to 5 years
> 18 kg
One tablet
AGE
CIPROFLOXACIN SYRUP
(250 mg per 5ml)
7 - < 15 kg
12 up to 24 months
1ml
15 - < 25 kg
2 up to 5 years
3ml
< 7 kg
2 up to 6 months
7.5 ml
4 ml
7 - < 10 kg
6 up to 12 months
10 ml
5 ml
10 - < 15 kg
12 up to 24 months
15 ml
7.5 ml
15 - < 25 kg
AGE
2 up to 5 years
20ml
The recommended treatment for POSSIBLE STREPTOCOOCAL INFECTION is IM Benzathine Benzylpenicillin (p. 37).
Only give oral penicillin if the caregiver refuses an injection.
If the child is allergic, use erythromycin instead.
PHENOXYMETHYL PENICILLIN
10 ml
38
WEIGHT
AGE
11 - < 35 kg
3 up to 5 years
SYRUP
(250 mg per 5ml)
TABLET
(250 mg)
5 ml
One tablet
Give Cotrimoxazole
Give from 6 weeks to all HIV positive or exposed children unless child is HIV NEGATIVE.
Continue cotrimoxazole until the child is shown to be HIV-uninfected and has not been breastfed for the last
6 weeks.
Give to all children with HIV INFECTION (criteria for stopping in children on ART are shown on p. 59 Step 4).
COTRIMOXAZOLE SYRUP
WEIGHT
2 - < 3.5 kg
tab
3.5 - < 5 kg
tab
WEIGHT
400/80 mg
2.5 - < 5 kg
2.5 ml
tablet
5 - < 14kg
5 ml
tablet
14 - < 30kg
10 ml
30 kg
5 - < 10 kg
1 tab
10 - < 12.5 kg
1 tabs
12.5 - < 15 kg
1 tabs
15 - < 20 kg
2 tabs
20 - 25 kg
2 tabs
25 kg
3 tabs
COTRIMOXAZOLE TABLET
39
800/160 mg
1 tablet
tablet
2 tablets
1 tablet
Follow the general instructions for every oral medicines to be given at home.
Also follow the instructions listed with the dosage table of each medicine.
Do not change the regimen of children referred from hospital or a TB clinic without discussing this with an expert
Treatment should be given as Directly Observed Treatment (DOT) 7 days a week.
Follow-up children each month (p. 52) to check adherence and progress.
Use this regimen in children with all forms of severe TB (extensive pulmonary TB, spinal or osteo-articular TB
or abdominal TB) or retreatment cases.
All children should receive four medicines during the intensive phase (Rifampicin/INH (RH), pyrazinamide
(PZA) and ethambutol) for two months. This is followed by RH for a further four months (continuation phase).
For small infants dissolve one dispersible PZA tablet (150 mg) in 3 ml of water.
To make ethambutol solution, crush one tablet (400 mg) to a fine powder and dissolve in 8 ml of water. Discard
unused solution.
Add Pyridoxine 12.5 mg daily for 6 months if the child is HIV positive or malnourished
WEIGHT
CONTINUATION
PHASE
FOUR MONTHS
Once daily
INTENSIVE PHASE
TWO MONTHS
Once daily
REGIMEN 3A
RH
(60mg/60)mg
PZA
PZA**
(500mg) OR150 mg/3 ml
RH
(60mg/60mg)
CONTINUATION
PHASE
FOUR MONTH
Once daily
INTENSIVE PHASE
TWO MONTHS
Once daily
REGIMEN 3B
PZA**
PZA
150 mg/3
OR
(500mg)
ml
ETHAMBUTOL
400mg/8ml solution OR
400 mg tablet
RH
(60mg/60mg)
1.5 ml
1ml
tab
tab
2.5 ml
1.5ml
tab
3 ml
2ml
1 tab
WEIGHT
RH
(60mg/60mg)
2 - < 3 kg
tab
EXPERT
ADVICE ON
DOSE
3 - < 4 kg
tab
2 - < 3 kg
tab
EXPERT
ADVICE ON
DOSE
1.5 ml
tab
3 - < 4 kg
tab
tab
2.5 ml
tab
4 - < 6 kg
1 tab
tab
4 - < 6 kg
1 tab
tab
3 ml
1 tab
6 - < 8 kg
1 tab
tab
3ml
1 tabs
6 - < 8 kg
1 tab
tab
1 tabs
8 - < 12 kg
2 tabs
tab
tab
2 tabs
8 - < 12 kg
2 tabs
tab
2 tabs
12 - < 15 kg
3 tabs
1 tab
tab
3 tabs
12 - < 15 kg
3 tabs
1 tab
3 tabs
15 - < 20 kg
3 tabs
1 tab
1 tab
3 tabs
15 - < 20 kg
3 tabs
1 tab
3 tabs
20 - < 25 kg
4 tabs
1 tabs
1 tab
4 tabs
20 - < 25 kg
4 tabs
1 tabs
4 tabs
25- < 30 kg
5 tabs
2 tabs
1 tabs
5 tabs
25- < 30 kg
5 tabs
2 tabs
5 tabs
40
Give the current malaria treatment recommended for your area. See the Malaria Treatment
Guidelines.
Treat only test-confirmed malaria. Refer if unable to test, or if the child is unable to
swallow, or is under one year of age.
Record and notify malaria cases.
SALBUTAMOL
MDI - 100 ug per puff:
Watch the caregiver give the first dose of Co-ArtemR in the clinic and observe for one hour.
If the child vomits within an hour repeat the dose.
Give Co-Artemether with fat-containing food/milk to ensure adequate absorption. food.
Give first dose immediately
Second dose should be taken at home 8 hours later. Then twice daily for two more days.
WEIGHT
< 15 kg
1 tablet
15 - 25 kg
2 tablets
41
WEIGHT
AGE
PARACETAMOL SYRUP
(120 mg per 5 ml)
3 - < kg
0 up to 3 months
2 ml
5 - < 7 kg
3 up to 6 months
2.5 ml
7 - < 9 kg
6 up to 12 months
4 ml
9 - < 14 kg
12 months up to 3 years
5 ml
14 - < 17.5 kg
3 years up to 5 years
7.5 ml
MEDICAL COMPLICATIONS
WEIGHT
3 - < 6 kg
6 - < 10 kg
10 - < 25 kg
Age
Only if you do not
know the weight
Ferrous Gluconate
(40 mg elemental
iron per 5 ml) OR
0 up to 3 months
3 up to 12 months
One up to 5 years
RUTF
500Kcal/92gm sachet
WEIGHT
Sachets
(per day)
Sachets
(per week)
4 - < 5 kg
14
0.3 ml
( dropper)
2 .5 ml
0.6 ml
(1 dropper)
5.0 ml
0.9 ml
(1 dropper)
tablet
5 - < 7 kg
18
7 - < 8.5 kg
21
25
28
10.5 - < 12 kg
32
12 kg
35
Give Multivitamins
Give prophylaxis dose to child with Low birth Weight or Preterm from the third week of life
Give to children with Severe Acute Malnutrition not on feed with combined mineral and vitamin
complex (CMV) or Anaemia
MULTIVITAMINS
Once Daily
AGE
Drops
Birth to 6
weeks
All other children
< 2.5 kg
0.3 ml
2.5 kg
0.6 ml
Syrup
WEIGHT
ELEMENTAL ZINC
Once daily
Up to 10 kg
10 mg
> 10 kg
20 mg
5 ml
42
2. Give Zinc
3. Continue Feeding
4. When to Return
NB The contents of the ORS sachet is mixed with clean water and administered
to correct dehydration.
SHOW THE CAREGIVER HOW MUCH FLUID TO GIVE IN ADDITION TO THE
USUAL FLUID INTAKE:
Up to 2 years
50 to 100 ml after each loose stool.
2 years or more
100 to 200 ml after each loose stool.
2.
3.
4.
43
1.
2.
3.
4.
* Exception:
Another severe
classification
YES
Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Weigh the child or estimate the weight.
Give Normal Saline IV:
(children).
NO
Reassess the child after 3 hours if he/she is still at the clinic. Classify dehydration. Then choose the appropriate plan (A, B, or C) to
continue treatment. Refer the child to hospital even if he/she no longer has severe dehydration.
If caregiver refuses or you cannot refer, observe child in clinic for at least 6 hours after he/she has been fully rehydrated.
Is IV treatment
available nearby
(within 30 minutes)?
YES
nasogastric tube.
NO
Are you trained to
use a nasogastric
(NG) tube for
rehydration?
NO
Can the child drink?
YES
Start rehydration with ORS solution, by tube: give 20 ml per kg each hour for 6 hours (total of 120 ml per kg).
REFER URGENTLY for further management.
Reassess the child every 1-2 hours while awaiting transfer:
If there is repeated vomiting give the fluid more slowly.
If there is abdominal distension stop fluids and refer urgently.
After 6 hours reassess the child if he/she is still at the clinic. Classify dehydration. Then choose the appropriate plan (A, B, or C)
to continue treatment.
NO
Refer URGENTLY
to hospital for IV
or NG treatment
NOTE:
f possible, observe the child at least 6 hours after rehydration, to be sure the caregiver can maintain hydration giving the child ORS by mouth.
44
For Thrush
If there are thick plaques the caregiver should:
Wash hands with soap and water.
Wet a clean soft cloth with chlorhexidine 0.2% or salt water, wrap this around
the little finger, then gentle wipe away the plaques.
Wash hands again.
Give nystatin 1 ml 4 times a day (after feeds) for 7 days.
If infant is breastfed,
Check mothers breasts for thrush. If present treat mothers breasts with
nystatin.
Advise mother to wash nipples and areolae after feeds.
If bottle fed, change to cup and make sure that the caregiver knows how to clean
utensils used to prepare and give the milk (p. 22 - 24)
45
2. WHEN TO RETURN
Advise caregiver to return immediately if the child has any of these
signs:
Any sick child
Becomes sicker
Not able to drink or breastfeed
Has convulsions
Vomiting everything
Develops a fever
Fast breathing
Difficult breathing
Wheezing
Blood in stool
Drinking poorly
FOLLOW-UP VISIT: Advise caregiver to come for follow-up at the earliest time listed for the
If the child has:
PNEUMONIA
DYSENTERY
SOME DEHYDRATION - if diarrhoea not improving
MALARIA - if fever persists
SUSPECTED MALARIA - if fever persists
FEVER - OTHER CAUSE - if fever persists
MEASLES
SUSPECTED MEASLES
2 days
5 days
7 days
14 days
HIV-INFECTION
ONGOING HIV EXPOSURE
SUSPECTED SYMPTOMATIC HIV
HIV EXPOSED
TB EXPOSED
CONFIRMED or PROBABLE TB
Monthly
46
3.
5.
If the caregiver is sick, provide care for her, or refer her for help.
If the mother has a breast condition (such as engorgement, sore nipples, breast infection), provide care or refer her for
help.
Advise the caregiver to eat well to keep up his/her own strength and health.
Check the mothers immunisation status and give her tetanus toxoid if needed.
Encourage caregiver to grow local foods, if possible, and to eat fresh fruit and vegetables.
Ensure that the childs birth is registered.
Where indicated, encourage the caregiver to seek social support services e.g. Child Support Grant.
Make sure the caregiver has access to:
Contraception and sexual health services, including HCT services.
Counselling on STI and prevention of HIV-infection.
Encourage disclosure: exclusive breastfeeding and possible ART are very problematic without disclosure.
Reassure her that with regular follow-up, much can be done to prevent serious illness, and maintain her and the childs
health.
Make sure her CD4 count has been checked and recommend ART if indicated.
Emphasise the importance of adherence if on ART.
Emphasise early treatment of illnesses, opportunistic infections or drug reaction.
Counsel caregiver on eating healthy foods that include protein, fat, carbohydrate, vitamins and minerals.
47
After 2 days:
Check the child for general danger signs
Assess the child for cough or difficult breathing
Ask: - Is the childs breathing slower?
- Is there less fever?
- Is the child eating better?
Treatment:
After 5 days:
See ASSESS & CLASSIFY (p. 26)
If there is chest indrawing or a general danger sign, give first dose of ceftriaxone IM. P. 36) Also
give first dose cotrimoxazole (p. 39) unless the child is known to be HIV-ve. Then REFER
URGENTLY.
Ask:
- Has the diarrhoea stopped?
- How many loose stools is the child having per day
Assess feeding
Treatment:
If breathing rate, fever and eating are the same, or worse, check if caregiver has been giving the
treatment correctly. If yes, refer. If she has been giving the antibiotic incorrectly, teach her to give
oral medicines at home. Follow-up in 2 days.
If breathing slower, less fever or eating better, complete 5 days of antibiotic. Remind the caregiver
Suggest caregiver gives one extra meal every day for one week.
After 2 days (PNEUMONIA with wheeze), or after 5 days (COUGH OR COLD with wheeze):
If wheezing has not improved, refer.
If no longer wheezing after 5 days, stop salbutamol. Advise caregiver to re-start salbutamol via
spacer if wheezing starts again, and return to clinic immediately if child has not improved within 4
hours.
DIARRHOEA
After 2 days (for some dehydration) or 5 days (for no visible dehydration, but not improving):
After 2 days:
Assess the child for diarrhoea. See ASSESS & CLASSIFY (p. 27).
Ask:
- Are there fewer stools?
- Is there less blood in the stool?
- Is there less fever?
- Is there less abdominal pain?
- Is the child eating better?
Treatment:
If general danger sign present, or child sicker, REFER URGENTLY.
48
If number of stools, amount of blood, fever or abdominal pain is the same or worse,
refer.
If child is better (fewer stools, less blood in stools, less fever, less abdominal pain,
eating better), complete 3 days of Ciprofloxacin.
After 14 days:
Weigh the child and determine if the child is still low weight for age.
Determine weight gain.
Reassess feeding (p. 18 - 20).
After 7 days:
TREATMENT:
If the child is gaining weight well, praise the caregiver. Review every 2 weeks until GROWING WELL.
If the child is still NOT GROWING WELL:
Check for TB and manage appropriately.
Check for HIV infection and manage appropriately.
Check for feeding problem. If feeding problem, counsel and follow-up in 5 days.
Counsel on feeding recommendations.
If the child has lost weight or you think feeding will not improve, refer. Otherwise review again after 14
days: if child has still not gained weight, or has lost weight, refer.
FEEDING PROBLEM
After 5 days:
Reassess feeding (p. 18 - 20).
Ask about feeding problems and counsel the caregiver about any new or continuing feeding problems
If child is NOT GROWING WELL, review after 14 days to check weight gain.
ANAEMIA
After 14 days: Check haemoglobin.
TREATMENT:
If haemoglobin lower than before, refer.
If haemoglobin the same or higher than before, continue iron. Recommend iron rich diet (p. 18). Review
in 14 days. Continue giving iron every day for 2 months (p. 42).
If the haemoglobin has not improved or the child has palmar pallor after one month, refer.
Ask:
Is the child feeding well?
Is the child is finishing the weekly amount of RUTF?
Are there any new problems?
Look for:
General danger signs, medical complications, fever and fast breathing. If present or
there is a new problem, assess and classify accordingly.
Weight, MUAC, oedema and anaemia
Do appetite test (p. 19)
Treatment:
If any one of the following are present, refer:
Any danger sign, RED or YELLOW CLASSIFICATION or other problem
The child fails the appetite test
Poor response as indicated by:
oedema
weight loss of more than 5% of body weight at any visit or for 2 consecutive
visits
static weight for 3 consecutive visits
failure to reach the discharge criteria after 2 months of outpatient treatment.
If there is no indication for referral:
Give a weekly supply of RUTF (p. 42)
Counsel the caregiver on feeding her child (p. 24)
Give immunisations and routine treatments when due (p. 35)
Follow-up weekly until stable
Continue to see the child monthly for at least two months until the child is feeding
well and gaining weight regularly or until the child is classified as GROWING WELL.
IF ANY MORE FOLLOW-UP VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR THIS VISIT, ADVISE THE CAREGIVER OF THE NEXT FOLLOW-UP VISIT.
ALSO, ADVISE THE CAREGIVER WHEN TO RETURN IMMEDIATELY (p. 46).
49
EAR INFECTION
Reassess for ear problem. See ASSESS & CLASSIFY (p. 30).
Treatment:
If there is tender swelling behind the ear or the child has a high fever, REFER
URGENTLY.
Treatment:
If the child has any general danger sign or stiff neck or bulging fontanelle, treat for SUSPECTED MENINGITIS (p. 28) and
REFER URGENTLY.
If fever has been present for 7 days, assess for TB. (p. 33)
After 5 days:
If ear pain or discharge persists, treat with amoxicillin for 5 more days.
Continue dry wicking if discharge persists.
Follow-up in 5 more days.
After two weeks of adequate wicking, if discharge persists, refer.
Treatment:
If the child has any general danger signs, bulging fontanelle or stiff neck, treat as SUSPECTED SEVERE MALARIA (p. 28)
and REFER URGENTLY.
If no improvement, refer
If malaria rapid test was positive at initial visit and fever persists or recurs, REFER URGENTLY.
If malaria test was negative at the initial visit, and no other cause for the fever is found after reassessment, repeat the test:
-
After 5 days:
Assess and monitor dehydration as some children with a sore throat are
reluctant to drink or eat due to pain
Stress the importance of completing 10 days of oral treatment.
If not improvement, follow-up in 5 more days.
After 10 days: If symptoms worse or not resolving, refer.
MEASLES
If fever persists after 2 days or caregiver complains of new problems, do a full reassessment (p. 2535)
Look for mouth ulcers and clouding of the cornea
Check that the child has received two doses of Vitamin A (p. 35)
Check that the necessary specimens have been sent and that contacts have been immunised.
Treatment:
If child has any danger sign or severe classification, provide pre-referral treatment, and REFER URGENTLY.
If child is still feverish, has mouth or eye complications, DIARRHOEA WITH SOME DEHYDRATION, PNEUMONIA or has
lost weight, refer.
If child has improved, advise caregiver to provide home care, including providing an extra meal for one week. Make sure she
knows When to Return (p. 15)
50
ALL CHILDREN LESS THAN FIVE YEARS OF AGE SHOULD BE INITIATED ON ART.
Children with this classification should be tested, and reclassified on the basis of their test
result.
Those older than five years should be assessed for ART eligibility (p. 54). Those meeting the criteria
should be initiated on ART. Children who do not meet the criteria should be classified as HIV
INFECTION not on ART, and should be followed up regularly (at least three monthly).
The following should be provided at each visit:
Routine child health care: immunisation, growth monitoring, feeding assessment and counselling
and developmental screening.
For all children under five: find out why the child is not on ART and counsel appropriately.
Cotrimoxazole prophylaxis (p. 39).
Assessment, classification and treatment of any new problem.
Ask about the caregivers health. Provide HCT and treatment if necessary.
Clinical staging and a CD4 count must be done at least six monthly to assess if the child
meets the criteria for initiation of ART (p. 54)
HIV EXPOSED
See the child at least once every month. At each visit provide:
Routine child health care: immunization, growth monitoring, and developmental screening.
Check if the child has been receiving prophylactic nevirapine. All infants of HIV-positive mothers
should receive nevirapine for 6 weeks. Some infants should continue to receive nevirapine for
long (p. 13)
Support the mother to exclusively breastfeed the infant (p. 21). If the infant is not breastfed, provide counselling on replacement feeding (p. 22-24) and address any feeding problems (p. 20)
Cotrimoxazole prophylaxis (p. 39).
Assess, classify and treat any new problem.
Test the child at six weeks (HIV PCR), and reclassify according to the test result.
Retest the child six weeks after cessation of breastfeeding.
Reclassify the child according to the test result and provide the relevant management.
Ask about the caregivers health. Provide counselling and appropriate management if necessary.
51
Follow-up monthly.
Follow-up monthly.
Ensure that the child is receiving regular treatment, ideally as Directly Observed Treatment, 7 days a
week. Remember to switch to the continuation phase after two months treatment (p. 40).
Counsel regarding the need for adherence, and for completing six months treatment.
Counsel and recommend HIV testing if the childs HIV status is not known.
52
If the child < 3 years or weighs less than 10 kg, use the regimen on p. 55 - 56
If the child is 3 years or older, and weighs 10 kg or more, use the regimen on p. 57 - 58
Remember to give cotrimoxazole (p. 39)
Give other routine treatments (p. 35)
Follow-up after one week
NOTE:
53
ADHERENCE PRINCIPLES:
Very high levels of adherence (> 95%) should be attained for adequate
Require fast-track (i.e. start ART within 7 days of being eligible with attention
to social issues, counseling and adherence )
STAGE 1
No symptoms
Persistent
generalised
lymphadenopathy
STAGE 2
STAGE 3
54
STAGE 4
ART: STARTING REGIMEN FOR CHILDREN LESS THAN 3 YEARS OLD (or < 10kg)
Give Abacavir
CHILDREN LESS THAN THREE YEARS OLD (or <
10 kg) RECEIVE THREE MEDICINES.
Abacavir
Lamivudine
Lopinavir/Ritonavir
A hypersensitivity (allergic) reaction to Abacavir may occur in a very small number of children. This usually
These are:
Common side-effect symptoms (p. 62) include fever and rash (usually raised and itchy)
Other symptoms include gastrointestinal symptoms (nausea, vomiting, abdominal pain) and respiratory
reaction is recorded, and that the patient knows that he/she should never take Abacavir again.
ABACAVIR (choose one option)
REMEMBER: Children who are started on this ARV regimen
should continue these ARVs even when they are older than
three years OR weigh 10 kg or more i.e. Do not change
regimen
REMEMBER to check the childs weight and appropriate dose
regularly - the dose will need to increase as the child grows.
WEIGHT
Solution: 20mg/ml
< 3 kg
Consult with expert for neonates (<28 days) and infants weighing < 3kg
3 < 5 kg
2 ml twice
daily
5 < 7 kg
3 ml twice
daily
7 < 10 kg
4 ml twice
daily
10 < 14 kg
6 ml twice
12 ml once
OR
OR
daily
daily
2 tablets
twice daily
OR
14 < 20 kg
8 ml twice
15 ml once
2 tablets
OR
OR
daily
daily
twice daily
OR
20 < 23 kg
10 ml
20 ml once
3 tablets
OR
OR
twice daily
daily
twice daily
OR
1 tablet once
daily
PLUS
23 - <25kg
3 tablets
20 ml once
10 ml
OR
OR
daily
twice daily
twice daily
OR
2 tablets once
daily
PLUS
55
Give Lopinavir/Ritonavir
Give twice daily ONLY
Give Lamivudine
WEIGHT
aplasia.
If side-effects are mild continue treatment.
< 3 kg
2 ml
twice daily
5 < 7 kg
3 ml
twice daily
10 < 14 kg
14 < 20 kg
20 < 25 kg
12 ml
once
daily
8 ml
OR
twice daily
15 ml
once
daily
15 ml
twice daily
30 ml
once
daily
OR
OR
OR
tablet
OR
twice daily
1 tablet
OR
twice daily
1 tablet
once daily
2 tablets
once daily
Tablets:
200/50 mg
Consult with expert for neonates (<28 days) and infants weighing < 3kg
5 < 10 kg
1.5 ml
twice daily
10 < 14 kg
2 ml
twice daily
14 < 20 kg
2.5 ml
twice daily
OR
2 tablets
twice daily
OR
1 tablets
twice daily
20 < 25 kg
3 ml
twice daily
OR
2 tablets
twice daily
OR
1 tablets
twice daily
25 < 30 kg
3.5 ml
twice daily
OR
3 tablets
twice daily
OR
2 tablets morning
OR One 100/25 mg tablet
and 1 tablet
PLUS
evening
One 200/50 mg tablet
30 < 35 kg
4 ml
twice daily
OR
3 tablets
twice daily
OR
2 tablets morning
and 1 tablet
OR
evening
35
5 ml
twice daily
OR
OR
1 tablet
once daily
56
Tablets: 100/25 mg
PLUS 200/50 mg
1 ml
twice daily
4 ml
twice daily
6 ml
OR
twice daily
Tablets:
100/25 mg
3 - < 5 kg
Tablet: 300 mg
Consult with expert for neonates (<28 days) and infants weighing < 3kg
3 < 5 kg
7 < 10 kg
Tablet: 150 mg
Solution:
80/20 mg/ml
OR
2 tablets
twice daily
These are:
Abacavir
Lamivudine
Efavirenz
See page 58
A hypersensitivity (allergic) reaction to Abacavir may occur in a very small number of children. This usually happens in the
first six weeks of treatment.
Common side-effect symptoms (p. 62) include fever and rash (usually raised and itchy)
Other symptoms include gastrointestinal symptoms (nausea, vomiting, abdominal pain) and respiratory symptoms
(dyspnoea, sore throat, cough).
If the child has at least 2 of the above, do NOT stop medicine but call for advice or refer URGENTLY..
If a hypersensitivity reaction is confirmed, Abacavir will be stopped.
A child who has had a hypersensitivity reaction must never be given Abacavir again. Make sure that the reaction is
recorded, and that the patient knows that he/she should never take Abacavir again.
REMEMBER
ABACAVIR
WEIGHT
Solution: 20mg/ml
Tablet: 300mg
(must be
swallowed
whole)
10 - < 14 kg
6 ml
12 ml
2 tablets
OR
OR
OR
twice daily
twice daily
once daily
4 tablets once
daily
14 - < 20 kg
8 ml
OR
twice daily
5 tablets once
daily
20 - < 23 kg
10 ml
20 ml
3 tablets
1 tablet once
OR
OR
OR
PLUS
twice daily
twice daily
daily
once daily
R
23 - < 25 kg
20 ml
3 tablets
2 tablets once
10 ml
OR
OR
OR
PLUS
twice daily
once daily
twice daily
daily
Tablet: Abacavir/
Lamivudine
600mg/300mg
(must be swallowed
whole)
2 tablets
15 ml
OR
OR
twice daily
once daily
OR
1 tablet once
daily
agents.
If available, use daily dose regimens.
1 tablet once
daily
1 tablet once
daily
>25 kg
57
ART: STARTING REGIMEN FOR CHILDREN LESS THAN 3 YEARS OLD (or < 10kg)
REMEMBER: Lamivudine and Efavirenz are given with Abacavir (p. 57)
Give Lamivudine
Give once or twice daily
Give Efavirenz
Solution: 10 mg/ml
Tablet: 150 mg
Tablet: 300
mg
Tablet: Abacavir/
Lamivudine
600mg/300mg
(must be swallowed
whole)
EFAVIRENZ
Give medication at night
WEIGHT
3 kg
Consult with expert for neonates (<28 days) and infants weighing < 3kg
3 - < 5 kg
2 ml
twice
daily
5 - < 7 kg
3 ml
twice
daily
7 - < 10kg
4 ml
twice
daily
10 - < 14kg
6 ml
twice
daily
12 ml
OR once
daily
14 - < 20
kg
8 ml
twice
daily
OR
15 ml
tablet
1 tablet
OR
once OR
twice OR
once daily
daily
daily
20 - < 25
kg
15 ml
twice
daily
OR
30 ml
once OR
daily
>25kg
Dose
10 - < 4 kg
200 mg
14 - < 5 kg
300 mg
25 - < 40 kg
400 mg
>40kg
600mg
50 mg
capsule or tablet
200 mg
capsule or tablet
(tablet must be swallowed whole)
600mg tablet
(must be swallowed
whole)
1 capsule/tablet at
night
2 capsule/
tablets at night
PLUS
1 capsule/tablet at
night
2 capsule/tablets at
night
1 tablet at night
1 tablet
2 tablets
1 tablet
OR
twice OR
once daily
once daily
daily
1 tablet
twice daily
OR
2 tablets
1 tablet
OR
OR
once daily
once daily
1 tablet
once daily
58
Check for main symptoms (p. 411 or 2534). Treat and follow-up accordingly.
Consider (screen for) TB: Assess, classify and manage (p. 34)
If child has TB, refer to next level of care.
REMEMBER cotrimoxazole can be stopped once the child has been stable on ART for at
least six months, the immune system is fully reconstituted and the child is > 1 year of age
(i.e. child 1 to 5 years of age: CD4 > 25%, or child > 5 years of age: CD4 >350 cells on 2
tests at least 3-6 months apart).
adherence counselling
Significant side-effects despite
appropriate management
Higher Stage than before
CD4 count significantly lower than
before
Viral load > 1000 copies despite
adherence counselling
Total non-fasting cholesterol
higher than 3.5 mmol/L
TGs higher than 5.6 mmol/L
Other
59
If the child is well, make an appropriate follow-up date in 1-3 months time,
taking into account repeat medication, blood results and clinical check ups.
If there are any problems, follow-up more frequently.
Children on Stavudine
Give twice daily
Change Stavudine to Abacavir if the viral load is undetectable or less than 50 copies/mL.
Do not wait for Stavudine side effects to switch to Abacavir
If VL is detectable REFER to the next level of care
Side effects include lactic acidosis, peripheral neuropathy and lipoatrophy
Refer children with severe vomiting and severe abdominal pain (URGENTLY), or with tingling or numbness of hands or feet (non-urgently).
Ask about and look for changes in appearance, especially thinness around the face and temples and excess fat around the tummy and shoulders.
STAVUDINE
WEIGHT
15 mg capsule
5 - < 7 kg
14 - < 25 kg
30 mg capsule
7 - < 10 kg
10 - < 14 kg
20 mg capsule
25 - < 40 kg
60
Test
Hb or FBC
Response
61
Management
Rash
If on Abacavir, assess carefully. Are there any signs & symptoms of Abacavir hypersensitivity: Is there any fever, nausea, vomiting, diarrhoea or abdominal pain? Is there generalized fatigue or achiness? Is there any shortness of breath, cough or
pharyngitis? If the child has at least 2 of the above, do NOT stop medicine but call for advice or refer URGENTLY.
If on Efavirenz or Nevirapine:
If the rash is severe and associated with symptoms such as fever, vomiting, oral lesions, blistering, facial swelling, conjunctivitis
and skin peeling, STOP all mediciness and refer URGENTLY.
If the rash is mild to moderate, with no systemic symptoms; the medicine can be continued with no interruption but under close
observation.
Advise that the medicines should be given with food. If persists for more than 2 weeks or worsens, call for advice or refer.
If vomiting everything, or vomiting associated with severe abdominal pain or difficult breathing, REFER URGENTLY.
Diarrhoea
Assess, classify and treat using diarrhoea charts (p. 5, 27, 43-44). Reassure caregiver that if due to ARV, it will improve in a
few weeks.
Follow-up as per Chart Booklet (p. 48). If not improved after two weeks, call for advice or refer.
Fever
Headache
Give paracetamol (p. 41). If on efavirenz, reassure that this is common and usually self-limiting.
If persists for more than 2 weeks or worsens, call for advice or refer.
This may be due to efavirenz. Give at night; counsel and support (usually lasts less than 3 weeks).
If persists for more than 2 weeks or worsens, call for advice or refer.
Ask about and look for changes in appearance, especially thinness around the face and temples and excess fat around the
tummy and shoulders.
If child on Stavudine: Substitute stavudine with abacavir if VL is less than 50 copies/mL.
If VL is greater than 50 copies/mL or if the child is not on stavudine, REFER.
If child develops enlarged breasts (lipomastia) which is severe and/or occurs before puberty, REFER.
62
IF SKIN IS ITCHING
LOOK
SIGNS
CLASSIFY
TREAT
FEATURES IN HIV
INFECTION
Is a clinical stage 2 defining case (p.
54)
PAPULAR
PRURITIC
ERUPTION
RINGWORM
(TINEA)
Apply Imidazole (e.g. clotrimazole 2% cream) three Extensive: there is a high incidence
times daily for two weeks
of co-existing nail infection which
Wash and dry skin well
has to be treated adequately to
Avoid sharing clothes, towels and toiletries (e.g.
prevent recurrence of tinea infecbrushes and combs)
tions of skin
Fungal nail infection is a clinical
stage 2 defining disease (p. 54)
Rash and excoriations on torso; burrows in web space and wrists. Face
spared
SCABIES
63
All close contacts should be treated simultaneously In HIV positive children, scabies
may manifest as crust scabies
(even if not itchy)
Crusted scabies present as extenCut finger nails and keep them clean
sive areas of crusting mainly on the
Wash all bedding and underwear in hot water
scalp, face, back and feet
Put on clean clothes after treatment
Patients may not complain of itching
Expose all bedding to direct sunlight
Apply sulphur ointment daily for three days
Do not continue if rash or swelling develops
Avoid contact with eyes, broken skin or sores
Treatment may need to be repeated after one
week (itching may continue for 23 weeks after
treatment)
LOOK
SIGNS
CLASSIFY
CHICKEN POX
HERPES ZOSTER
IMPETIGO
64
TREAT
Treat itching
Apply calamine lotion
In severe cases, give an oral antihistamine (see EDL for doses)
Refer urgently if Pneumonia or
jaundice appear (see p. 4, 26)
54)
NON-ITCHY
LOOK
SIGNS
CLASSIFY
WARTS
SEBORRHOEIC
DERMATITIS
65
TREAT
Incidence is higher
More than 100 lesions may be seen
Lesions often chronic and difficult to eradicate
Extensive molluscum contagiosum indicates Stage II HIV disease (p. 54).
LOOK
SIGNS
CLASSIFY
Stop medication
Give oral antihistamine
Then REFER
ECZEMA
cotrimoxazole or NVP
Lesions involve the skin as well
as the eyes and the mouth
Might cause difficulty in breathing
TREAT
Stop medication
REFER URGENTLY
trant to therapy
STEVEN JOHNSON
SYNDROME
66